Encompass Cares Foundation

Encompass Cares Foundation

Mission Grant Application

Please complete all sections of this application. Incomplete applications will be returned to the applicant, which may result in processing delays. Please allow 30 days following the due date for grant notification.

Today’s date: ______Mission trip dates:______

Destination country: ______

Name: ______

Address: ______

City, State, Zip: ______

Home phone: ______Work phone:______

Fax: ______

Encompass Location: Entity: ______Department: ______

Position:______

Encompass relationship status

Employee (20 hrs/wk minimum): Clinical ______Non-Clinical _____

Hours per week ______Years at Encompass_____

Retiree: Last job title ______Years at Encompass_____

Community Partner______

Sponsoring Organization

Name of organization: ______

Contact person: ______Phone: ______

Address: ______

City, State, Zip: ______Fax: ______

Financial Need

Actual airfare $ ______

Airfare request (maximum grant $750) $______

Medical supplies request (maximum grant $250) $______

Total grant request (maximum grant $1,000) $______

Proposal summary

Please describe this mission in narrative format, including:

. Your personal goals

. Your professional goals

. Your responsibilities as a mission participant

. Your motivation for being a volunteer

You must retain receipts for airfare and medical supplies. Copies are required after your trip.

Liability release

The Encompass Cares Foundation provides funding for employees, retirees and affiliated Encompass Home Health, Inc.to participate in overseas missions projects. Encompass and Encompass Cares has no legal obligation for the safety of the individual participant either from an accident, armed conflict, natural disaster or other cause for any reason. The Encompass Cares Foundation does not pass judgment on the needs of the particular community designated for a mission trip, nor does it provide information regarding current political and safety conditions of a country or destination. Mission applicants are advised to consult with the sponsoring organization regarding these issues. Accordingly the undersigned, in accepting a financial grant for a mission project, releases the Encompass Cares Foundation and Encompass, Inc. from any and all liability with respect to this mission project.

Signed: ______Date: ______Mission grant applicant